By Neil S Sadick; et al

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Drooping brow creates an unintentional tired and angry appearance. ● Eyebrows can be elevated by successful injection of the depressor musculature, thus permitting the brow elevators to act unopposed. Lifting is most likely the result of partial weakening of central frontalis fibers by diffusion of the toxin. ● Injecting 10–20 U Botox into the procerus and 5–10 U into each medial corrugator weakens the medial brown depressors, thus permitting frontalis to elevate the medial brow. ● In a study on dose range, Carruthers reported that approximately 30 U is an optimal dose for this indication.

1) ■ Informed Consent ● Document reasonable risks; best to prepare an informed consent document with an attorney familiar with local standards of care. Discontinuance of platelet-inhibiting drugs is controversial. This is especially important in more extensive ● Must delineate exact procedure, indications for therapy, treatment alternatives, and complication profile. 1 ■ Medications and Herbs That Can Affect Hemostasis Medications Mechanism of Action Details Aspirin Irreversibly inhibits cyclooxygenase Discontinue 7 days prior to injection Garlic Inhibits platelet aggregation and thromboxane B2 in vitro Taken for migraines, arthritis and cardiac health Ginger Enhances anticoagulant effects of Warfarin For use in management of nausea and vomiting NSAIDs (Non-aspirin nonsteroidal anti-inflammatory drugs Reversibly inhibit platelet COX-1 Discontinue 7 days prior to injection Plavix (Clopidogrel) Oral platelet aggregation inhibitor Discontinue 5 days pretreatment Vitamin E Decreases platelet adhesion Mild anticoagulant effect can be increased significantly when taken with aspirin and garlic Warfarin Oral Vitamin K antagonist Discontinue 3–4 days pretreatment 40 | Concise Manual of Cosmetic Dermatologic Surgery ● Consent for photography advisable.

21 (continued) C. Bilobed—2 months postoperative. D. Bilobed—2 months postoperative. E. 22 A. Forehead flap—immediately postsuture. B. 23 A. Ala defect. B. Rhombic—immediately postsuture. C. Rhombic—1 month postoperative ● ● Melolabial ● Rhombic ● Nasal ala ● Small and laterally placed defect? Consider a rhombic flap from the nose/cheek crease. ● Medial defect? Consider a V to Y advancement. ● Lateral defect? Consider a meilolabial flap. Ala ● ● Rhombic (Fig. 23) V to Y advancement ● Meilolabial (Fig.

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